Legislation

Search OpenLegislation Statutes
This entry was published on 2017-01-20
The selection dates indicate all change milestones for the entire volume, not just the location being viewed. Specifying a milestone date will retrieve the most recent version of the location before that date.
SECTION 1117
Health insurance plans for long term care
Insurance (ISC) CHAPTER 28, ARTICLE 11
§ 1117. Health insurance plans for long term care. (a) An authorized
insurer subject to the provisions of this chapter and organized to write
the kind of insurance specified in paragraph three of subsection (a) of
section one thousand one hundred thirteen of this article, a corporation
or health maintenance organization authorized pursuant to article
forty-three of this chapter or article forty-four of the public health
law, and a fraternal benefit society organized under article forty-five
of this chapter, may be authorized by the superintendent to issue
contracts in connection with plans providing benefits for long term
care, provided such plans satisfy the criteria set forth in subsection
(b) of this section and the superintendent has made the determinations
set forth in subsection (f) of this section.

(b) The superintendent may authorize such contracts in connection with
a plan for long term care pursuant to the following criteria:

(1) the plan's provisions are not misleading or confusing;

(2) the plan's provisions are not inconsistent with the needs of the
public;

(3) the plan's benefit structure provides options for use of long term
care services;

(4) the plan, the contract and other materials describing the plan
fully and clearly state the benefits and limitations of such plan;

(5) the authorized insurer, health maintenance organization, or
fraternal benefit society agrees to provide such reports of the
experience of the plan as may be requested by the superintendent. The
superintendent may prepare abstracts and summaries of such reports at
the request of other government agencies for purposes of research and
studies related to long term care financing, provided however that the
insurer, health maintenance organization, or fraternal benefit society
may request that specified information included in the report be
considered confidential; and

(6) prior to the earlier of the execution of a policy or certificate
in connection with a plan providing a home care benefit and/or a nursing
home benefit, or the payment of any premium or fee related to such a
policy or certificate, the authorized insurer, corporation, health
maintenance organization or fraternal benefit society shall provide the
prospective insured or his or her representative with a disclosure
statement, which contains the following:

(A) The maximum daily and lifetime benefit levels, if applicable,
provided by the policy or certificate for home care services and nursing
home services;

(B) The percentage of coverage provided for home care services and
nursing home services, if applicable, and an explanation of the
methodology on which the reasonable charge used in conjunction with such
percentage amount is based;

(C) A description of any inflation protection feature included in or
available for purchase under the policy or certificate and the
additional premium required to purchase such option or options;

(D) (i) If available and accessible by the insurer or other entity
from the department of health, the most recently-published average,
statewide rate for care in a nursing home, as well as the average rates
for care in nursing homes for both the New York city-metropolitan and
upstate regions of the state; or

(ii) If available and accessible by the insurer or other entity from
the department of health, the most recently-published map of the
estimated average regional rates in New York state for nursing home
care;

(E) A graphic demonstration of the maximum daily nursing home benefit
level provided by the policy or certificate, and the impact that the
selection of any inflation protection options would have on such maximum
daily nursing home benefit level; and

(F) The right of the prospective insured, upon attaining the age of
sixty-five years, to designate a third party who will receive a copy of
any notices of nonpayment of premiums due or notice of cancellation for
nonpayment of premiums that is sent to the prospective insured.
For the purpose of this paragraph, "home care services" shall have the
same meaning as defined in subdivision one of section thirty-six hundred
two of the public health law. The prospective insured, or his or her
representative, shall acknowledge that the required disclosure has been
made by signing the disclosure statement prior to or contemporaneously
with the effective date of the policy or certificate.
Failure to provide information required by subparagraph (D) of this
paragraph shall not be construed as a violation of this section if such
information has not been made available by the department of health.

(c) The duration of such contracts and the extent of exposure
thereunder by insurers, health maintenance organizations or fraternal
benefit societies shall be in the discretion of the superintendent.

(d) Contracts issued pursuant to the provisions of this section shall
be subject to all other provisions of this chapter and the regulations
promulgated thereunder applicable to the insurer, health maintenance
organization, or fraternal benefit society which issues the contract,
provided however that in order to permit the development of long term
care plans, the superintendent may modify or suspend any such provision
or regulation upon making the determinations set forth in subsection (f)
of this section.

(e) The superintendent may permit an authorized insurer, health
maintenance organization, or fraternal benefit society subject to the
provisions of this chapter to reinsure the risk of any long term care
services plan, provided such plan satisfies the requirements of this
section. Such reinsurance agreements shall provide for the payment of a
reasonable premium.

(f) The superintendent may take the actions set forth in subsections
(a), (d) and (e) of this section only if the superintendent determines
that:

(1) the plan is a legitimate approach to expand the availability of
insurance coverage for long term care services;

(2) any proposed modification or suspension of a provision of this
chapter or a regulation promulgated thereunder is essential to the
development of long term care plans pursuant to this section, and is
directly related to the essential features of such plans;

(3) the premium rates for the long term care plan are reasonably
related to the benefits provided, and are self-supporting; and

(4) the plan proposed by the insurer, health maintenance organization,
or fraternal benefit society, and any proposed modification or
suspension pursuant to subsection (d) of this section, will not cause or
constitute an impairment of the insurer's, health maintenance
organization's, or fraternal benefit society's ability to satisfy its
existing and anticipated contracts and other obligations, including such
standards as the superintendent shall prescribe concerning adequate
capital and financial requirements.

(g) (1) Except for certain group contracts described in paragraph four
of this subsection, in order for premium payments for long-term care
insurance to qualify for purposes of section one hundred ninety,
subdivision twenty-five-a of section two hundred ten, subsection (aa) of
section six hundred six, subsection (k) of section one thousand four
hundred fifty-six and subsection (m) of section one thousand five
hundred eleven of the tax law, the long-term care insurance must be
approved by the superintendent pursuant to this subsection. Prior to
approving any such insurance, the superintendent shall conclude that it
meets minimum standards, including minimum loss ratio standards under
this section or section three thousand two hundred twenty-nine of this
chapter and is a qualified long-term care insurance contract as defined
in section 7702B of the internal revenue code.

(2) (A) No insurer, agent, broker, person, business or corporation
doing business in or into this state shall in any manner state,
advertise or claim that a long-term care insurance policy qualifies for
purposes of the above-referenced provisions of the tax law unless
either: (i) the superintendent has issued a letter or other written
instrument to the insurer stating that the policy has been determined to
qualify under this subsection, or (ii) the policy qualifies under
paragraph four of this subsection without the need for approval by the
superintendent.

(B) Any policy which is held out or purported to be a long-term care
insurance policy by any insurer, agent, broker, person, business or
corporation doing business in or into this state which has not been
determined by the superintendent to qualify and which does not qualify
under paragraph four of this subsection for purposes of the above
referenced provisions of the tax law shall so state clearly, legibly and
in close physical proximity to any description of the policy as a
long-term care insurance policy that it does not so qualify. This
subsection shall also be deemed to cover any statement, advertisement or
claim concerning such policy by any insurer, agent, broker, person,
business or corporation doing business in or into this state.

(C) Violation of this paragraph shall be considered a
misrepresentation under section twenty-one hundred twenty-three of this
chapter.

(3) The superintendent shall maintain an ongoing list of those
policies requiring approval of the superintendent that are found
eligible for purposes of the above-referenced provisions of the tax law.

(4) Group contracts delivered or issued for delivery outside of the
state, but which are qualified long-term care insurance contracts as
defined in section 7702B of the internal revenue code shall be deemed to
qualify for purposes of the provisions of the tax law specified in
paragraph one of this subsection without the need to seek the approval
of the superintendent pursuant to this subsection. Provided that they
otherwise meet the requirements of this paragraph, such group contracts
include, but are not limited to, those offered: (a) by professional
associations and societies, membership organizations and not-for-profit
groups, or by a subsidiary or affiliated entity of any of the foregoing,
to the members of the association, society, organization or group, and
(b) by employers to their employees.